ulceration Flashcards
what is an oral ulcer
break in epithelial lining
what is erosion
thinning of epithelium
- not an ulcer
what is RAS
- intermittent episode of oral aphthous ulcers in healthy individuals
-late childhood presentation
-diagnosis - clinical, history and exclusion of medical cause - No cure
- common, painful, recurrent
prevalence of RAS
- varies by population
- 1 in 4 people
aetiopathogenesis of RAS
- idiopathic
- close associations/risk factors
what are some strong associations of RAS
- positive family history
- non-smoker or cessation of smoking
- trauma (considered a trigger) - crisps, braces
- haematininc deficiencies
- age <30 years
- cytokine polymorphism
- HLAS
what are some weaker associations of RAS
- female gender
-growing children - higher socio-economic status
- high stress
- food intolerance - benzoates
- hormone imbalance - pre-menstrual period
- SLS- containing toothpaste and drugs
immunologic responce in RAS
- increase B lymphocytes, NK cells, T cells
-reactivation and hyperactivity of neutrophils - high level of the complement system ingredients
-preponderance of pro inflammatory TH1-type cytokines - limited expression of anti-inflammatory Th2- type cytokines and TGF-B
-decreased expression of HSP - decreased CD4 lymphocytes
how to diagnose RAS
- clinical diagnosis
- medical history
-ulcer history
-systems inquiry
what questions should be asked in ulcer history
- onset - what age
- number - multiple or one
- duration
- frequency
- pattern
- location - eating drinking speaking, cheek near front may not bother but large oropharyngeal ulcer may stop them speaking
- size - bigger than cm?
- pain - tongue particularly sore
- prodrome - feel run down before it ?
- associated symptoms - night sweats, illness
- triggers - diet diary
- relievers - bonjela (salycilic acid not ideal for mouth), corsydyl
- previous treatments
- impact on QOL
what questions in medical history should be asked for ulcer diagnosis
- any medical problems
-attending any hospital specialists ? - any medications - doses
- systems enquiry
When diagnosing ulcers what is important to ask about the GI system
- weight loss
- constipation
- diarrhoea
- bloating
- reflux
- blood in stool
how may RAS present on exam
- round
- grey base
-erythematous halo
what is this
minor RAS
how may minor RAS present
- less than 1cm(<10mm)
- 7-10 days
- non keratinised mucosa
- no scarring
- low number of ulcers
- tend to be on stretchy bits of mouth
how may major RAS present
- greater than 1cm
- last longer than 2-3 weeks
- can affect all mucosa
- heal with scarring
how may herpeteform RAS present
- multiple tiny ulcers
- resemble herpetic ulcers
- can coalesce
- keratinised surface
- often effects tongue
- can present with systemic effects
what is this
herpetiform RAS
investigations to diagnose ulcers
- if otherwise healthy - RAS
- bloods
- standard (FBC, haematinics, coeliac screen)
- additional (ESR, ANA, viral screens(HIV etc), immunoglobins
- referral to specialists to exclude underlying conditions
- biopsy - +/- direct immunofluorescence
what is aphthous like ulceration
presentation of RAS in association with variety of systemic disordered and medications
what conditions are associated with aphthous like ulceration
- bechets
- IBD
- crohns
-ulcerative colitis - HIV
-PFAPA
-sweets
1st line management of RAS
- diet modification - healthy, no benzoate
-trauma - dentist fix - toothpaste - SLS free
- benzydamine
-lidocaine
-covering agent
-chlorhexidine
2nd line management of RAS
- topical corticosteroids - betamethasone, hydrocotisone
- topical antibiotics - doxycycline
- vitamin b12
- laser - ablative or non ablative
3rd line management of RAS
- systemic corticosteroids
-prednisalone
-biologics
-azathioprine
what is bechets
- chronic, relapsing, multisysyem, inflammatory vasculitis
- affects large and small vessels
- affects whole body
cause of bechets
- unknown
- genetic predisposition
- auto inflammatory disease
symptoms/presentation of bechets
- ulcers - RAS- deeper and last longer
- mouth ulcers, genital ulcers, eye inflammation, skin issues, bowel issues, headache
how to diagnose bechets
- international criteria for bechets
- 4 = diagnosis
genital ulcers, oral ulcers , ocular lesions = 2
positive pathergy, skin lesion = 1
Tx of bechets
- Similar to RAS
- corticosteroids
- covering agent
- lidocaine
how to treat traumatic ulcers
remove the cause
what is TUGSE
- traumatic ulcerative granuloma with stromal eosinophilia
- self limiting , rare, benign
what is the aetiology of TUGSE
- unknown - ulcer stuck in healing
-consider differential diagnosis in patients with
dry mouth
ulcers
complex MH
elderly
Tx of TUGSE
- resolution after biopsy
-topical/intra-lesional steroid
how may TUGSE present
- side of tongue
-white halo - granulating
-doesn’t heal
medications which cause ulcers
- cytotoxic drugs - methotrexate
- NSAIDS - ibuprofen , aspirin
- Nicorandil (angina)
infections which can cause ulceration
- TB
- HSV 1 and 2
- Primary syphillis infection
- Marcella zoster
-epstein barr virus
how may a syphillis ulcer present
- solitary and painless
what is this
TUGSE
which other conditions can present with ulceration
- lichen planus
-blistering conditions
how does ulceration occur in blistering conditions
- unstable epithelium
- if rubbed will blister, collapse and then ulcer
- common on buccal mucosa, FOM and soft palate
how may a traumatic ulcer present
- white keratotic border
- causative agent
- surrounding mucosa normal and ulcer soft
features of an ulcer which make it a higher cancer risk
- exophytic
- rolled borders
- raised
- hard to touch
iatrogenic causes of ulcers
- chemo
-radiotherapy
-graft versus host disease
-drug induced ulceration
how may neoplastic ulcer present
- exophytic
- rolled border
- raised
- hard to touch
- non moveable
- not always painful - numbness
- sensory disturbance
